Our Health Our Action

Tandrusti Research Report

Foreword

The Workers EducationalAssociation (WEA) is the largestvoluntary provider of adulteducation in the UK. The WEA isone of the UK’s biggest charities,and operates at local, regional andnational levels. Nine Regions inEngland, a Scottish Association andover 650 local Branches make upthe WEA’s National Association.

Within the West Midlands region we design and deliverformal and non-formal lifelong learning opportunities toeducationally, socially and economically disadvantagedadults. These opportunities include research activities,projects and programmes in a wide range of communitylocations, often in partnership with statutory and/orvoluntary and community organisations. Our focus is onwidening participation and social purpose, addressingissues such as health and well being, communityinvolvement and employment.

Tandrusti, meaning health and well-being in the mainAsian languages, is a leading-edge WEA West Midlandsproject that has used a community education approach toexplore and promote the benefits of physical activity andhealthy living amongst Black and Minority Ethnic (BME)communities in Dudley Metropolitan Borough. This isachieved through the provision of free, local andstructured bespoke exercise programmes in an adulteducation context making use of community venues and alimited amount of gym equipment that is stored andtransported to various localities.

Tandrusti has run successfully for seven years followingfunding from the National Lottery, Dudley Primary CareTrust (PCT) and the Workers' Educational Association.

During this time, the project staff team has establishedexcellent working relationships with several partners andcontributed to a range of health networks addressinglocal priorities within the Borough.

The Department for Communities and Local Government(DCLG) funded action research project is an excellentopportunity to build on the success of the Tandrustiproject and reaffirm the vital role of adult education –and the WEA – in health improvement. The researchaimed to identify health needs among people from a widerange of BME communities and further developpartnerships with public bodies (such as the PCT) toshape future service provision within health deprivedwards in Dudley.

The findings within this research report provide richinsight into health patterns and help identify barriers andinequalities to healthy living. The challenge now is tocontinue to tackle identified barriers by working withpartners to engage people in appropriate healtheducation courses around different health conditions tohelp meet local targets around improving the health oflocal people.

Also, to secure funding to further develop the role ofcommunity health volunteers to encourage people toadopt sustainable healthy lifestyles outside of Tandrustiprogrammes and activities. To achieve this we need to beable to plan ahead over several years and secure staffing,management and finance for future work.

An executive summary of this research report, togetherwith further information about the Tandrusti project, canbe found by visitingwww.westmidlands.wea.org.uk/tandrusti

Howard Croft Regional Projects Coordinator WEA West Midlands Region

The Tandrusti research project is supported by theDepartment for Communities and Local Government(DCLG) via the Connecting Communities Plus programme

Contents

1. Introduction...............................................................................3

2. Research Background..............................................................4

3. Methodology ...........................................................................10

4. Research Findings....................................................................12

5. Conclusions.............................................................................20

6. Recommendations ................................................................22

7. References ...............................................................................25

4

The Dudley area is one of the mostsocio-economically deprived areaswithin the West Midlands; with highprevalence of poverty,unemployment and the associateddeprivations in education, housingand health.

Dudley has 12 areas with a total population of 18,000 asthe most deprived 10% of people in the country (IMD2004). Although Dudley has a relatively small (at 6.3%)Black or Minority Ethnic Background (BME) population,certain wards have high numbers of BME groups and thesetend to be the poorest wards. Consequently BME groups inthese wards bare the brunt of these inequalities anddeprivation.

The Tandrusti (A sound condition of the mind and body inPunjabi) Project (established in 2001) has been animportant tool in bringing a much needed health and fitnesseducation facility to the community. The project attracts avaried mix of learners from Dudley and the Black Country,which include people of all ages, ethnicities and abilities.The Tandrusti project’s forward looking approach to

improving the health of BME groups prompted a need for in-depth research which extended beyond the evidentstatistical improvements in BMI (Body Mass Index) andBlood Pressure (BP) readings of its learners.

The Tandrusti research project was developed as a means ofpro-active health needs assessment of Black and MinorityEthnic (BME) groups within the Dudley borough of the WestMidlands. Its objectives were to trace the health journeys of180 questionnaires followed by 50 indepth interviews withBME individuals living within Dudley and surrounding areasthrough in-depth interviewing. These health journeys consistof both Tandrusti service users and non-service users. Theelicitation of health journeys provided a qualitative insightinto the health status of BME groups and helped to identifybarriers and inequalities. Moreover, the research findingshave an overall strategic aim to institute effective workingrelationship with public bodies to consequently reducehealth inequalities. The findings of the research will bedisseminated and shared to influence and shape futureservice provision for BME groups both within Tandrusti andbeyond. An essential developmental strategy of the researchwas to recruit 25 Community Health Champions willing tobe trained and mentored as part of the capacity buildingstrategy of Tandrusti. This volunteering strategy isanticipated to aid sustainable and more embedded healthimprovement approaches for BME groups in Dudley throughproactive health education and development.

Introduction

Research Background

5

Why research Black and MinorityEthnic health in Dudley?

n Health issues presented by black and minority ethnicgroups are disproportionate to non BME groups

n A lack of in-depth and qualitative research into localhealth needs and health experiences of BME groups

n High risk factors for BME Groupsn Language difficultiesn Lack of familiarity with the health service systemsn Cultural barriersn Effects of racism and discriminationn Ethnic differences in GP consultationsn Hospital care for ethnic minoritiesn Lower referral rate for outpatient services for ethnic

minority groupsn Health inequality is just a component of wider

structural inequalities i.e. higher incidence ofunemployment and homelessness among BME groups,who tend to live in inner cities and socially andeconomically deprived areas with related healthinequalities

What has previous health researchon Black and Minority Ethnic groupsshown?

Ethnicity and health

There is a growing body of evidence (Bhopal 2002,House, 2002 Karlsen and Nazroo, 2004) from research tosuggest that ethnic minorities suffer the greatestdisadvantages in terms of health. However the measuresused to investigate the relationship between ethnicity andhealth often fail to consider central aspects of ethnicminority experience which may influence health;particularly the impact of socio-economic disadvantageand racial harassment and discrimination. Findings fromUK based research (Karlsen and Nazroo, 2004) suggestthat around one in eight people from ethnic minoritygroups experience some form of racial harassment eachyear on the basis of their ethnicity or religion. The term ethnicity needs to be approached with somedegree of caution to ensure that apparent racial and orbiological disparities are not used to define ethnicitywhich is much more fluid, transient and diverse. Inaddition using racial, biological or cultural differencesreinforces notions of ethnicity as a form of ‘otherness’.The problem arises as ethnic groups have been and stillremain the ‘other,’ an identifiable group or groups whomaybe blamed for problems within a society orcommunity. To date the term ethnicity is predominatelyused to refer to non-white groups, and it has been easier

to blame a collective group for having a bad diet, or forbeing immoral or ignorant with regards to health. This isthe easy scapegoat for underlying structural issues ofinequality that BME groups are likely to be at thereceiving end (Modood, 1997). This however, is notarguing that ethnic differences have no role to play inunderstanding and improving their health, but highlightingthat different groups have different needs. In additionmost waves of immigrations over the past century andmore recently have settled in urban, inner city areaswhere poverty and deprivation and health and social risksare already present. Hence this has implications on thehealth services but also uproots tensions and hostilitiesbetween the new immigrants and the settled communitieswho are at the lowest end of the socio-economic level ascompetition for scarce resources and services intensifies(Modood, 1997).

High Risk factors in health for BME Groups

The relationship between BME groups and poor healthhas been made apparent in much medical and socialresearch (Hayes, White, Unwin et al 2002, Rankin andBhopal 2000, Bhopal 2002). In particular the high ratesof mortality and high morbidity from coronary heartdisease (CHD) in South Asian people in the UK comparedto the rest of the European origin population has beenthe subject of much discussion and research. The causesare not yet fully understood, however there is somegeneral consensus on the high risk factors that makeSouth Asians more susceptible to developing CHD thanother groups. These high risk factors include obesity,insulin resistance or diabetes and low high densitylipoprotein cholesterol (Bhopal, 2002). The explanationsfor these risk factors are entangled in a political debateof socio-economic focus and all subsequent lines ofenquiry in the research repeatedly rebound to thisstructural issue of socio-economic deprivation. Forexample, research (Macintyre et al 2004) suggests thatthe high risk of developing CHD in South Asians can besignificantly reduced through regular physical activity;simultaneously there is also the evidence to suggest thatSouth Asians are less likely to participate in physicalactivity (Johnson 2000) than other Europeans. Hence tounderstand the reasons for South Asians being lessphysically active, some examination of the structuralinequalities that persist in our society, existing in theform of inaccessible health services, poor healtheducation, and lack of facilities and time to exercise isrequired. An element of the research findings focuses onthe particular experiences of health services of BMEgroups in Dudley.

6

Research Background

Socio-economic disadvantage and health

People from black and minority ethnic (BME) backgroundsmake up 8% of the UK population. (ONS, 2001). Evidencesuggests that rates of mortality and ill-health tend to beworse in BME groups compared to the general populationand that their health problems are more severe. Healthinequalities may result from many different interlinkingfactors such as genetics and lifestyle. However researchsuggests much of the differences can be attributed to thefact that BME groups are generally poorer than the ethnicmajority. The current Labour Government has made thereduction of health inequalities a key priority as outlinedin the various parliamentary papers. For example, ‘TacklingHealth Inequalities’: A Programme for Action (2003) andChoosing Health (2004) Our Health, Our Care, Our Say(2006) have all included an agenda or proposal on thereduction of health inequalities which undoubtedly affectethnic minorities to a greater extent. Furthermore on 22January 2007, the Parliamentary Office for Science andTechnology published a Policy Note (Ethnicity and health)which examines the extent of ethnic inequalities in health,the evidence for what factors determine them and thepossible policy options.

Research on social inequalities in health has consistentlydocumented the inverse relationship betweensocioeconomic position and health (House, 2002).

Numerous studies have reported that higher levels ofeducation, occupation, income, and wealth are associatedwith better health during adulthood. This social gradientin health has been observed for a wide range ofoutcomes, including physical and mental morbidity,psychological well-being, and mortality (Brand et al2007).

Socio-economic inequalities for BME groups in health aremost commonly revealed through high rates of diabetes,prenatal mortality, high prevalence of coronary heartdisease, stroke and inequalities in mental health (Nazroo1997). This national survey research, into ‘The health ofBritain’s ethnic minorities’ led by the Policy StudiesInstitute (PSI) revealed some stark differences betweenthe health and health experiences of BME individuals andthat of non BME groups. The main findings revealed; thehealth and wellbeing of individuals from ethnic minoritybackground is likely to be poorer than that of whitepeople. The study shifted focus from the previousassociations for poor health between biological andcultural factors where the blame lay primarily on thelifestyles and genetics of the BME groups to consideringa whole array of influencing factors. The debate of howsignificant the variable of socio-economic background isin the equation of BME health outcome is ongoing but itspresence and impact on the health of all ethnic groups isdocumented widely. Nazroo’s (1997) argument of the

7

Research Background

significance of soico-economic background on the healthof BME’s is made compelling through the nationalstatistics and data indicating certain ethnic minorities(namely, Pakistani, Bangladeshi and African Caribbeanindividuals) who are the poorest groups in the country ashaving the poorest health in the country. Therefore thesubsequent impingement of poverty has detrimentaleffects on all facets of the individuals’ life chancesincluding their health.

As well as measurable indicators of poor health throughnational statistics and statistics from the Department ofHealth, BME individuals also have the poorest selfreported health than non-BME groups. Variations betweenethnic groups apparent in West Midlands data on self-reported health from Census 2001 are similar to those inEngland and Wales as a whole. For example:n Pakistani and Bangladeshi men and women were most

likely to report their health as 'not good'.n Proportions of Black Caribbean and Indian women

reporting their health as “not good” were alsorelatively high.

n Chinese men and women were the least likely toreport their health as 'not good'.

n Pakistani and Bangladeshi men and women and BlackCaribbean and Indian women had the highest rates oflong-term illness or disability. (Census 2001: HealthStatistics, Office for National Statistics)

Diet and health behaviour

Dietary habits are strongly culturally defined humanbehaviours and are also extremely unstable, affectingpeople’s health in different ways. It is known that a dietrich in plant foods like fruits and vegetables may helpprotect against heart disease and some forms of cancers.Conversely, diets providing a lot of saturated fat areassociated with an increased risk of these diseases.Ethnic minority populations typically have poorer healthprospects than the indigenous population (Dowler 2001).Levels of obesity are rising amongst several ethnicminority groups and this has highlighted a geneticsusceptibility to a number of chronic diseases, includingheart disease, diabetes and stroke, to varying extents indifferent sub-groups. For example, The Health Survey forEngland (2004) found that South Asian men were moreat risk of angina and heart attack than others, with BlackCaribbean and Indian men having a greater risk of stroke.The survey also found that all minority ethnic groupsapart from the Irish and Chinese were likely to suffer ahigher rate of diabetes (Erens et al 2001).

Eating patterns within any cultural group can be verydiverse. Dietary practices, particularly within the SouthAsian community, are heavily influenced by religiouspractices (e.g. fasts, festivals) and beliefs (e.g. foodrestrictions and laws). However, contrary to sometheories, the traditional diet of many ethnic minoritygroups contains a large amount of starchy carbohydratefoods (e.g. cereals, rice, yams, and potatoes, pulses,

vegetables and fruit). In comparison with the UKpopulation, those adopting such diets have a higherconsumption of complex carbohydrates and a lower fatintake (Hamid and sarwar 2004). Their diets are,therefore, closer to the national nutritionalrecommendations than might be otherwise assumed.Thus, the factors contributing to health outcomes aremulti-dimensional, complex and not possible tocompartmentalise as independent variables hence theyneed to be examined as interrelated and heterogenicfactors which vary from individual to individual.

The intake of ingredients in diets is important but evenmore important is the method used to prepare or cookthe ingredients from their raw form (Hamid and Sarwar,2004). It has been documented that many ethnicminority groups purchase their food from ethnic foodstores, and a lot of the food is bought fresh withminimum inclusion of processed food in the diet. Howeveroil, fat and spices in Indian cooking are proven to bedetrimental to health and thus the awareness of a healthybalanced diet which is prepared healthily coupled withregular physical activity seem to be the ideal equilibriumto maintain.

Physical activity among BME Groups

Part of Tandrusti’s success has been its localisedapproach to health and fitness for BME groups whoseeffects are not examined in much detail in previousresearch. For example Tandrusti has been able to attractand retain female South Asian learners in the 50 + agegroup, which according to previous studies have been thegroup which is the least physically active compared to allother groups (Johnson 2000). Despite having thisfundamental access to this group, the need to fullyunderstand their health histories, health experiences andhealth awareness is paramount in informing future healthand fitness developments in Tandrusti of a holistic kind.Perceptions and attitudes towards physical activity heldby BME groups have indicated some cultural differencesbut overall are similar to other inactive groups.

For example an integral piece of qualitative research byRai and Finch (1997) found that there was a combinationof barriers to physical activity for BME communities.These barriers could be grouped under two main types ofbarriers; barriers of a practical nature and barriers relatingto attitudes and beliefs. In terms of practical barriersthese included; a lack of time and a lack of suitable andaffordable facilities. The attitudinal barriers included; alack of motivation, lack of role models, stress andfinancial pressures and the priority that was given tophysical activity generally. They found some variationbetween different ethnic groups within the main types ofbarriers of a cultural and community specific type. Forinstance, in the case of South Asians the practicalbarriers consisted of issues like; not feeling comfortableto wear gym clothes in a mixed gym or their husbands orfamilies not approving of them exercising when they

should be concentrating on domestic issues. Moreover theattitudinal barriers mainly consisted of prioritising familyobligations over personal preference and also beliefsaround old age being a period of resting rather thanexercising. However, despite the seemingly culturallyspecific nature of these barriers, they were also found tobe affecting some non BME groups to a lesser extent.

The low participation of BME groups in physical activityhas been documented by a recent national survey bySport England. This Active People’s Survey (2006) wasthe largest survey in Europe which provided some uniquestatistics on people’s active recreation and physicalactivity levels in over 350 local authorities within theBritain with over 360,000 people being interviewed bytelephone. The findings revealed that the adult physicalactivity levels in the West Midlands region was quite lowoverall with 19% of the adult population taking partregularly in sport and active recreation compared to thenational figure of 21%. More importantly, the sport andrecreation levels of people from BME groups (16.5%) andor from low socio economic groups (14.7) were alsosignificantly lower than the national average. Themethodology of the research maybe debatable in itsaccuracy but nevertheless it provides a strong statisticaloverarching picture of the physical activity levels ofpeople from various geographical regions andbackgrounds.

The reasons behind the significantly low participation inphysical activity of certain groups is changeable overtime, place, demographics and cultural processes which allhave evolving traits. However, previous research by AlliedDunbar National Fitness Survey (ADNFS) part of SportEngland, has attempted to explain these reasons usingstatistical approach. The survey was completed in 1992and documented responses from over 4,000 peopleacross Britain. It grouped the reasons given by people fornot exercising into 5 main categories: 1) Physical barriers(age, previous Injury etc) 2) access and availability (noclothes or equipment costs) 3) Time constraints, 4)emotional reasons (fear of injury, shyness etc) or 5)Motivation. What was more interesting was that theresponses indicated some marked ethnic differences bothwithin ethnic groups and between those sub groups andthe national picture. Without reinforcing ethnicstereotypes, the findings highlighted some interestingconclusions in terms of religious and cultural differencesas apparent barriers to participation in physical activity.These included issues of modesty and avoiding mixedgyms, perceptions among Bangladeshi’s that they weretoo old and needed to rest, feeling that they are notsporty and the general approach of putting familyresponsibilities before physical activity.

On the surface the differences seemed quite starkbetween various ethnic groups, but these reasons wereexpanded upon by further qualitative research whichshowed the reasons were not always culturally orethnically bound as might be first perceived. The

qualitative research by Johnson (2000) broke down theSouth Asian community into various sub groups to drawout the differences and similarities and found there to becommon over arching barriers to a lack of physicalactivity among these groups which predominately involvednot having enough time, money or motivation and thelevel of importance they placed on physical activityrelative to other commitments. Those with moreeducation and economic wealth viewed physical activityto be integral to their lifestyle regardless of their actualparticipation which was an attitudinal advantage that wasabsent in a significant number of individuals from pooreducational and poor socio-economic backgrounds.

In addition the motivation to participate in physicalactivity for the Asian community is affected by the socialand leisure interests of BME groups and the availability ofaffordable facilities and services within their local vicinity.Lovell (1991) found that the sports that Asian people sawthemselves as fitting into included badminton, tennis,cricket and squash. However, the facilities for thesessports are not typically found in inner city deprived areaswhere a majority of ethnic minorities still reside despitetheir capacity for socio-economic mobility.

Research has shown that a key factor to motivatingpeople into leading a healthy lifestyle is effective healthpromotion, having some network of informal support orhaving a realistic role model that they can relate to andbe guided by. The evident lack of BME role models andineffective health promotion targeted at BME groups hasbeen unproductive in the past according to Bhopal andWhite (1993) and they suggest:“Health promoters need to understand the social historyof ethnic minorities including their culture, changingcircumstances….political problems, of which racism is ….perhaps the greatest concern…such understanding is hardto acquire. (Bhopal and White 1993, p141)

The problem behind some of the health promotiontargeted at ethnic minorities is the top down, ‘one sizefits all’ and culturally inappropriate advice and healthinformation that fails in the delivery and impact of keyhealth messages to BME groups. A project that was setup by the Hartcliffe Heath Health and Environment Groupin 1990 addressed this particular issue of ethnic minorityhealth within a deprived area (Hartfield) of Bristol. Theproject deployed a bottom up approach and built up ademocratic and self sustaining model of health promotionand ill health prevention which was led by the localcommunity and they themselves identified their needsthrough a thorough evaluation and understanding of thecommunity and its particular needs. The project wasinitially a short term project but its clear success andcapacity building ability led to the long term developmentof the project and consequently became an embeddedcomponent of the Hartfield area.

8

Research Background

9

Research Background

Health service use by BME Groups

The UK population makeup is becoming increasinglycosmopolitan with waves of migration both historicallyand more recently. Migration is a norm despite theimmigration overload panic that some politicians infuse inpeople’s minds through the media. The right to healthcare is the natural right of every citizen; however, BMEpatients seem to be confronted with barriers when usinghealth services (Garrett et al, 1998). The barriers whichmay exist in the form of demographic barriers (age,gender and marital status) or social/structural barriers(ethnicity, education, social class and economic status,living conditions and family support) can all pose asimpending obstacles to the access and quality of healthcare that BME groups experience. Numerous quantitativeand qualitative studies have differed on the conclusionson the root causes of the poor service use experience byethnic minorities.

While some (Perez-Stable et al, 1997 Eshiett and Parry2003) have maintained that the patient level barrierssuch as language and cultural differences between ethnicminority patients and care providers are the mostsignificant in determining the access and quality ofservice, others have argued conversely. They argue that tounderstand health inequity, a much more strategic andcritical focus needs to be placed on the potential barriers

that ethnic minority health service users are likely to face.Furthermore the heterogeneity and at times the ambiguitythat surrounds the term ‘ethnic minority’ may lead to amisguided understanding and consequent misguidedapproaches to tackling health inequality at the providerand system level. The Department of Health’s RaceEquality Scheme 2005-2008 (a requirement of the RaceAmendment Act of 2002) has put the NHS Trusts undera legal obligation to provide access and quality healthservice use to all individuals regardless of gender,ethnicity, income and age. The Equality and Human RightsCommission monitors and evaluates the Race Equalityclause and have highlighted the difficulty in monitoringeffectively has been primarily because of the lack of datathat GP surgeries collect on their patients in terms ofethnicity and experiences of use. Moreover the LondonHealth Observatory highlighted that only one third ofhospitals coded their data and similarly very few GPsurgeries collected data on their patients and this hasproved to be a useful tool for not only updating theirrecords but also reflecting on and evaluating theirpractices.

While there is a lack of coherent data on the ethnicity ofpatients within the NHS, there have been numerousqualitative and quantitative studies which have been ableto document some continuing inequalities within thehealth care system (Smaje, 1998). These inequalities

10

Research Background

manifest in the form of persistent insufficiency intranslation and language support in GP surgeries at whicha large number of people who may not have English astheir first language are registered. Other notions ofinequality however, are more complex than what they mayappear on the surface, for example low GP referral of BMEgroups to out-patient services and differences in GPconsultation with BME groups compared to non BMEgroups. Although satisfaction with GP services issomewhat lower for BME groups compared with non-BMEgroups the levels of satisfaction are quite high overall.Research suggests this may be due to the perceivedbenevolent nature of the GP service whereby the GPs arethere to help and provide a much valued and highlydeemed service to the community or simply the need andexpectations people have of the GP service. In additionthe absence of overt racial discrimination and theconfidence in the doctors’ professionalism may all becontributing factors in helping to understand patientssatisfaction levels.

A recent piece of qualitative research by ETHNOS (2008)identified the factors influencing Black and Asian people’sperceptions of racial discrimination within GP surgeries asbeing related to their personal experience of racialdiscrimination and being of lower socio-economicbackground. Although there are many explanations forprejudice and discrimination in society one of the keydrivers is known to be the competition for scarce publicresources. Many BME communities initially settled inalready deprived areas with high levels of inequalities inmany facets of the public and private arena other thanhealth. Accordingly, racial and discriminatory attitudesdevelop towards the ‘outsider’ or the ‘foreigner’ whomaybe perceived to be benefiting from the health care

that the indigenous group should have priority to.Consequently one explanation is that the pressures onthe health services in these deprived inner city areas maybe the underlying cause behind subsequent inequalitieswhich may appear to be racially motivated but not alwaysthe case (Ibid).

This however is not denying the experiences of racialdiscrimination of those who have experienced it withinthe health services and it is by no means denying the factthat there must be a whole host of reasons whyinequality in the outcome of services exist i.e. in lowreferral of BME to outpatient services.

On the whole although BME patients are much more likelyto use the GP services than non-BME groups the accessof services does not always account for quality of service,as the high use of GP service by BME groups could be aresult of poor access and awareness of other healthservices or possible low satisfaction with the outcome ofthe initial GP consultation. Furthermore BME patients aremore likely to be given a prescription by their GP.Research suggests that this may not always be due toneed for prescription but inadequate communication andresources leading to a ‘veterinary consultation’ in whichthe prescription is offered to the patient as a non verbalway of terminating the interaction (Gill et al, 1995).Although this may appear to be a crude conclusion,comparative research with other European countries hasshown a much lower rate of prescribing than Britain(Hahn, 1995). Therefore the higher rate of prescription,lower outpatient referral rate and frequent GP visits byBME groups highlight some questions around the qualityof health service in Britain with regards to BME patients.

Methodology

11

The aims and objectives of theTandrusti project required aqualitative research approach to betaken, the nature of the researchwas critical social research as itaimed to interpret and influencechange in the health and fitnessprovision of BME groups in Dudley.

In this case; the experiences and health histories of BMEgroups within the Dudley area provided a backbone fordevelopmental and innovative strategies endeavouring tomeet the health needs of the groups in question. Criticalsocial research is based in a reflexive paradigm wherebyreality is viewed as ideological and hence theinterpretation of BME responses as well as the macrostructures of society had to be examined in relation totheir impact on the group being studied (Harvey, 1990).

Sample

The recruitment of 50 interviewees was unproblematicand in fact over 30 additional interviewees also wantedto be interviewed, which contradicts the widely usednotion of ‘hard to reach groups’. The only issue that wasof some concern at this stage was the lack of BME malesin the sample and therefore links were established withlocal community centres to arrange for their gatekeepersto provide access to potential BME male interviewees.This sampling method consequently snowballed until anappropriate representation of BME males was attained.Through this sampling method and through promoting theproject within a community health fair and communitynetworking meetings, further interviewees who were notusing the Tandrusti services were identified and recruitedas a means of comparison to the Tandrusti service users.

To ensure confidentiality and consent, all intervieweessigned formal consents and they were debriefed of theresearch objectives and interview outcomes to ensurethey knew what they were participating in and also givingthem the opportunity to withdraw at any time. Thereforethe statement of ethical practice outlined by the BritishSociological Association was referred to and adhered toat all stages of the research (BSA, 2002).

Methods

The method utilised for this approach was semistructured interviews; this established a foundation fordiscussion without restricting the dialogue to a closedquestion and answer discourse (Rapley, 2004). Thismethod enabled there to be a more fruitful discussion toemerge from people who are less vocal and less likely toprovide a lot of detail to very open ended questions.Efforts were made by the researcher to build relationshipsprior to interviews so interviewees felt comfortable intalking about their personal issues. This proved highlyvaluable as the mutual trust meant that the interviewswere fluid and more intrusive questions could becontentedly asked and responded to. More importantly,this rapport was of vital significance as the power andautonomy the researcher had in the interview processsomewhat diminished and there were conversations on arelatively equal footing. During the course of theinterviews the researcher’s role was critically reflectedupon equally to determine the possible influence this mayhave on responses generated.

Throughout the interviews, certain discursive points weremade to prompt dialogue which then facilitated in makinginterviewees feel comfortable in talking about theirpersonal health experiences. However, every intervieweeresponded differently to the interview and the questionsasked, thus requiring flexibility on the part of theresearcher to direct any meandering discussion back tothe interview agenda in a sensitive and gradual manner(Collins 1997). This was a reluctantly necessary measuredue to time constraints on many of the interviews.Nevertheless, the benefits from the rapport and flexibilitywere illustrated in the rich and detailed accounts thatwere drawn from the interviews. The interviewees feltconfident to divulge some very intimate and sensitivestories and many referred to the researcher as being like adaughter or sister which assisted in the development oftrust without compromising the requisites of the research.

The actual interviews (not including the general spiel atthe start and end) lasted from 20 minutes to 45 minutesdepending on the time constraints (i.e. some intervieweesdid not have much time) and the general talkativeness ofthe interviewee. However, every effort was made to makethe interviewee comfortable in terms of conducting theinterview at a venue and time of their choice as well as inthe language which they felt most comfortable in. Inaddition the researcher met all the interviewees informallyon a regular basis by coming to the class and evenparticipating in the exercises.

12

Methodology

Interview Practicalities

Due to practical constraints in terms of just a singleresearcher conducting the interviews, it was necessary totape as many interviews as possible as well as takingadditional notes on non verbal communication, gesturesand intonations. It was necessary to tell a story from eachinterview rather than present a hard script, thereforethose reading the transcript would be able to understandand envisage the actual interview as best as possible inturn this also assisted in later analyses.

Most interviewees (except 4) felt comfortable in beingtaped after being assured that no other person wouldlisten to their interview; although anonymous transcriptsmaybe cross checked by other colleagues. A few peopledeclined being taped as they didn’t feel comfortable andwanted complete anonymity so their wishes had to berespected and thus ensure the data gained was nottainted by the apprehension felt by the interviewees.Subsequently, careful note taking had to be used wherebyresponses were noted and then interviews transcribedimmediately after to capture the interview as accuratelyand with as much detail as possible. Moreover, to ensurecomfortable and coherent dialogues with interviewees amajority of the interviews were conducted in thecommunity languages and therefore had to be translatedbefore transcription, coding and analysis.

Data Analysis

All the data was in interview form with some additionalnotes made from class visits and participation in some ofthe exercises. The mere volume of qualitative data had tobe carefully analysed to ensure a valid and accurateinterpretation of interviewee responses. Therefore amethod of constant comparative analysis was used viaeach interview transcript; this coded responses and drewout themes and issues continually until no new themesemerged (Hewitt-Taylor 2001). These themes were allcollated to depict commonalities in themes and issuesbetween interviews to then make comparisons. Thisprocess supported the development of the final analyticalthemes to be used in the discussion of findings.

All taped interviews were transcribed in as much detail aspossible to the interview questions as attempts weremade to capture smiles, laughing and some body gestures

in the interviews which are not always apparent in audiointerviews. The non verbal language of interviewees alsohelps to establish any uneasiness and trepidation aroundcertain topics as well detecting contradictions betweenbody language and words. For example a woman referredto her GP as being ‘very good’, but whilst doing so sherolled her eyes and smiled which indicated some sarcasmand disarray in her comment. This required some furtherclarification for the purpose of the tape as well as notingthe seemingly insignificant gesture as part of thediscourse on GP service use and satisfaction.

The first stage of analysis involved familiarisation with thedata generated by the interviews and identification of keyand emerging issues to inform the development of athematic framework. This is a series of thematic matricesor ‘charts’ into which interview data is comprehensivelysummarised. Each matrix or chart represents a particulararea of enquiry covered by the study. Within each ofthese charts the column headings on each of the chartsrelate to sub-themes within the area of enquiry coveredby the chart. The rows on each of the charts relate toindividual respondents, with each participant having his orher own row so that data from the same individual orcase can be reviewed together by reading across the row.

Once the charts were established, data for each case wasthen summarised in the relevant cell. Data from theinterviews was comprehensively summarised, so that all ofthe content of the interview is included, albeit in asummarised form. The context of the information isretained and the page of the transcript from which it isderived is noted, so that it is possible to return to atranscript to explore a point in more detail or extract textfor a verbatim quotation. This approach makes theinterview data more accessible to comprehensive andconsistent analysis while, at the same time, making surethat links with the verbatim data are retained.

The use of a framework enabled the views, circumstancesand experiences of all participants to be explored within acommon analytical framework which is both grounded inand driven by participants’ accounts. The approach allowsfor in-depth case analysis as well as for cases to becompared and contrasted. It also allows for patterns andthemes to be identified and explored and for explanationsand hypotheses about observed patterns andassociations to be generated.

Research Findings

13

The aim of the 50 qualitativeinterviews with BME individualswithin the Dudley area was to gaina detailed understanding of theirhealth profile, needs and service usein an attempt to build on the issuesraised in the previous quantitativeTandrusti health survey carried outwith over 180 individuals.

Health Histories

It was important to construct a health profile of theindividuals who offered to participate in the research. Theaim of this was to understand the health of individualsprior to taking part in the Tandrusti project. Moreover,through the process of recalling health experiences in thepast, participants could reflect on their health andlifestyle practices more critically and think about theimportance of previous lifestyle practices as having animpact on health subsequently. What became apparentthrough the interviews was that participants talked abouttheir health in the past in a somewhat positive manner.For example the absence of any diagnosed disease orhealth problem was seen as a sign of good health bymany of the participants. Subsequently they describedtheir health as being good in the past as they didn’t havethe health problems and health conditions that they havedeveloped now. However, when asked to give more detailsthey attributed their good health in the past to theabsence of disease and being young.

There were a few individuals who had been rather healthconscious in the past but on the whole the recognition ofone’s personal health status developed when confrontedwith illness or disease. Some participants had taken apositive stance to improving their health afterexperiencing some illness or threat of illness either firsthand or through those close to them. In these individualsthere was a more critical reflection on their lifestyles andhealth status in the past and some regretted notparticipating in any physical activity in their younger yearsafter seeing the negative effects of physical inactivity andcontrastingly the positive effects of physical activitythrough participating in the Tandrusti project.Nonetheless the majority did not see any fault with theirlifestyles in the past and present and viewed illness anddisease as an inevitable cycle of aging.

“My health in the past has been really good, I can’tcomplain, I didn’t have any illnesses then and now as Ihave got older I’ve got diabetes, high blood pressureand a cholesterol problem.”

“I am old now so I have to expect that my health will bequite bad and a lot of people get diabetes and heartproblems…..when I was young and fit I didn’t have anyof these complications its just part of old age…..so nowit means I have to look after my health more and I canteat all the oily food that I used to eat when I was young(laughs)”

“I hardly saw the doctor when I was young, and now Iam having to go regularly to check my diabetes, astime goes by you need to see the doctor more as youget all these illnesses which you didn’t have when youwere young.”

As the above interview extracts demonstrate, manyparticipants placed a strong focus on cure rather thanprevention to health problems. The health services wereaccessed mainly for curative purposes to their healthproblems and this gave an indication of their levels ofhealth awareness and other health information and advicethat surmise preventative health measures. Theassessment of participants’ health awareness was basedon their ability to be critically aware of their personalhealth status and also having understanding ofbehavioural, lifestyle and attitudinal aspects contributingto eventual poor health. Thus, participants were askedquestions around access and use of health informationand advice as well as their awareness of food contents,their motivation towards staying healthy, particularaspects such as having a health role model, barriers togaining health information and staying healthy.

Health Awareness

The data from the interviews revealed that participantshad a rather generic, ‘text book’ style and rehearsedunderstanding of how to stay healthy and thus on surfacethe participants’ knowledge of having a healthy livingseemed adequate. However, further probing revealed littleevidence of the practical application of that healthknowledge in their day to day lives, thus it could beconcluded that often people’s health knowledge can notbe taken as a measure of their health awareness andhealth status. This can be particularly problematic toconstrue when a quantitative approach is taken towardsunderstanding people’s health and there isn’t a means ofextracting a fuller and more justified understanding oftheir health awareness.

14

Research Findings

The issue of particular significance to many participantsfrom the South Asian community in the interview samplewas the problems faced in contextualising and applyinghealth information into life styles due to the lack ofculturally relevant information. The importance of havingculturally competent health information is paramount inhealth promotion targeted at certain BME groups from aSouth Asian background who have limited command ofthe English language in spoken and/ or written form.Culturally competent information involves havingtranslated material in community languages but alsofinding ways and techniques of getting that informationto the community which will be relevant to their lifestyles,cultural and religious practices. This may require a morecarefully targeted and prescriptive approach gearedtowards research and evaluation of health needs of acommunity followed by need specific health promotionand health intervention. Therefore, when participants wereasked about the basics of healthy living they knew aboutexercise, eating healthy and drinking plenty of water.However probing on diet, for example; revealed theirknowledge was rather limited and despite being able tolist vegetables and fruit which are beneficial to health, theactual use in day to day meals in a healthily preparedmethod was infrequent.

Disparity in perceived and actualhealthiness of diet

Having a healthy and varied diet rich in the vitamins andnutrients is vital in supporting the body to maintain ahealthy weight and reduce the risk of a number ofdiseases including heart disease, stroke, cancer, diabetesand osteoporosis. The objective behind understanding thedietary habits of the participants was to gain insight intoboth the value that is placed on diet as an integralcomponent to staying healthy and also what kind of foodparticipants consume and the perceived health benefits oftheir diet.

With a national media campaign to improve people’s dietsmany participants have been able to translate and relaykey health messages. However, a number of participantshad very poor awareness of what they were consumingand the related nutritional information for certain foodand diet. This was communicated in their perception ofhow healthy their food was and how healthy their foodactually was. The disparity could be understood throughthe fact that their understanding of healthy eating wasfocussed on knowing that having fruit and vegetables inthe diet were important and not necessarily on thequantities that need to be eaten or the preparationtechniques which ensured their most healthyconsumption. Despite the importance of participantsknowing this health message, the practice of this in daily

Marie Willets has been with Tandrusti for several years now and travels all the wayfrom Kidderminster to come to the class on a Monday morning. She attends the

class regularly and finds the class to be helpful to herphysical, emotional and social development. Shebelieves the mixed ethnicity group is usefulto community cohesion and she wouldlike to support this type of communitycohesion through her volunteering.However, she views communitycohesion as beyond ethnicity andinclusive of different age groups as

well and has encouraged her granddaughter who is starting herstudies in health and social care to become a volunteer forTandrusti. Marie offered to become a Community HealthChampion for Tandrusti to support elderly isolated peopleand to help them to increase their health awareness andsupport them with their emotional health as contributingfactor to other health problems.

“Its so important that

people mix in this way, that

is one of the benefits of

this class you meet a whole

range of people and we can

all support one another.”

Case Study 1 - Marie Willets

15

Research Findings

diets was absent, and when vegetables were consumed inthe diet they were often prepared in such a way wherethe nutrients from the vegetables were lost (Nursal andYucecan, 2000). More importantly the awareness of howeating a diet rich in fresh ingredients, vegetables and fruitcan benefit the health was quite poor. It was here thatthe widely relayed health messages on the 5 a day fruitand vegetables was not contextualised and notappropriated to diverse groups and diverse lifestyles.

Moreover, many participants’ judgment of healthy eatingwas intertwined with the notion of eating less as meaninghealthy eating. This was particularly the case with femaleparticipants who often thought that because they wereeating only two meals during the day, their diet washealthy despite the sugar, fat and salt in take beinghigher in those meals. Hence, they were eating two mealsof bigger portions and which were less healthy. The healthpolicy and media focus on healthy eating has establishedan efficient platform to launch healthy eating messagesand more explicit nutritional information on food labels.Participants in this research expressed little awareness offood labelling and rarely read them regardless of theirliteracy levels and ethic background.

“I know what kind of foods are really fattening andwhat is bad for your heart… things like burgers, pizza’s,chips and cakes… you wouldn’t have to check the foodlabel on that you would just know that is not good foryour health.”

“I never check the food labels as they don’t really makeany sense to me, I don’t look at the more detailedlabels but just things on the front like, ‘low in fat’ ‘lowin sugar’.”

“We don’t shop from the supermarket very often, mostof our groceries and meat is fresh from the Asianshops, they don’t have labels on them… I think knowingwhat food is healthy is common sense… I have learnedthings from my mother and then I got married andcame here and then you see things on TV, you pickthings up from family and friends and you learnsomething new all the time...”

Accessing Health Information

The level of health awareness of participants was alsoaffected by their literacy levels in that those who wereliterate in a language were able to access healthinformation a lot better than those who were not. A smallnumber of the literate/educated participants were alsomore active in building up their health knowledge throughtheir own research via reading health books, magazinesand using the internet. Consequently their heightenedhealth awareness was having an impact on their lifestylesand their positive approach to improving their healththrough exercise and healthy eating. On the whole theolder participants over the age of 65 were less active inbuilding their health knowledge but more imperatively the

health promotion material was less effective in reachingthem. Their main source of health information was theirGP and through interactions with friends and family. Itwas apparent that many health messages were notgetting through. Although their theoretical understandingof being healthy was adequate, it seemed being healthywas something that was intended for other people, i.e.exercise was for younger and healthier people and notpeople who were older and/or suffering from one orseveral health conditions.

After some brief research, one was able to discover anabundance of information and services offered by theNHS, Department of Health and various otherorganisations which qualify as culturally competent healthinformation but it seems the access and awareness ofthese services is not as successful. This may be anindication of the top down and authoritarian approachtaken where service users are not as proactive in theprocess of health promotion as the health information isgiven to the participants to follow in a rather dictatorialway. Interestingly this was not specific to the BMEparticipants but a general trend in people’s response tohealth promotion, whereby written health information wasseen to be less effective in getting the message across.For many participants the more informal and interactivehealth information which may be communicated throughthe family, friends, exercise tutors and even TVprogrammes was more practical and helpful. Manyparticipants believed that when health information wasdispensed in this way, it enabled them to be moreproactive in the health promotion process by askingquestions and talking about their health at the sametime. Reducing the amount of professionalism in healthpromotion was a key factor which helped to graspparticipants’ interest and motivation to improving theirhealth in a realistic and appealing way. The discrepancieswhich exist between health professionals and marginalisedor disadvantaged service users (which favour healthprofessionals) in the form of educational professionalism,cultural capital and material advantage are potentialbarriers to fluid, helpful and effective health promotion.Eric Rofes’s (1998) Ethnographic research in the USidentified that health promoters often exacerbate theproblem by unwittingly associating ‘healthy’ with being‘moral’ and ‘good’ and ‘unhealthy’ ‘risky with being‘immoral’ or ‘bad’ which often has the opposite desiredeffect.

Raising motivation and havingpositive role models

Health promotion is just one part of the puzzle tounderstanding the barriers to healthy living faced by BMEgroups. A key under-researched aspect is the lowmotivation to be healthy of individuals who both haveinsufficient and sufficient health awareness. This is partlydue to the complexity in trying to measure motivationlevels on a quantitative scale as most research has

16

Research Findings

tended to do. For this research the interpretation ofparticipants’ motivation levels was not accounted for byquantitative indicators but rather left open ended andconsequently it was woven in and out of the variousdiscussions within the interviews as an underlying yetsignificant aspect of participants’ behavioural andattitudinal patterns towards health. It became clear fromthe outset that participants found real life/ realistic rolemodels to be more productive in motivating towardshealthy living. The term role model, however, needed someclarification and explanation due to the subjectiveperceptions of participants who saw it as an ‘ideal’ orsomeone that they are likely to be in awe of rather thanbe motivated by realistically. Moreover, a number ofparticipants saw their spouses as role models which wasunproblematic theoretically as it provided the realisticrole model that they could relate to and work withtogether in improving their health. However, in moredetailed dialogues on what ways their spouses/rolemodels did to motivate them, the outcome seemed lessencouraging and more damaging emotionally and in termsof their confidence.

“My husband says I need to lose weight… he said I’mtoo fat”.

“He just tells me that I should eat less and lose weight,but its not that easy… I have had 4 children and I’m alot older now so I cant be like I was when I wasyounger. He is quite lucky as he naturally quite slim,but he doesn’t really exercise or eat healthy but it’sharder for me.”

These interview extracts illustrate the issue of the lack ofrole models in the participants’ life quite well and alsothe misunderstanding of what a role model actuallysignifies. This had to be clarified in many interviews, asmotivation is inextricably linked to having self confidenceand having a network of positive support, which wasclearly lacking for a number of participants. On the whole12 out of the 50 people interviewed claimed to have arole model, most of whom were either spouses or familymembers. The support from these proclaimed role modelsvaried from positively and proactively encouraging topatronisingly and profusely negative. Furthermore manyrole models gave advice in the form of ‘don’ts’ and notwhat to ‘do’ i.e. don’t eat this don’t eat that’.Consequently nearly all participants felt that their healthawareness and knowledge could be improved.

Dispelling subjective interpretationsof recommended physical activity.

Alongside healthy eating, physical activity is an essentialcomponent to staying healthy and reducing the risk ofpotentially fatal diseases and obesity. Less than one fifthof the people interviewed for this research were doing theideal or sufficient recommended (30 minutes of moderateactivity 5 times a week) amount of physical activity

during the week. The rest were either sedentary or doinginsufficient exercise and in some cases it wasinappropriate due to ill health. This was problematic notdue the fact they were not doing sufficient exercise butmore so because they believed they were doing asufficient amount of physical activity based on anunsubstantiated count of the number of times they werewalking; doing housework or thought they were being‘active’. The focus on the frequency of physical activityrather than the amalgamation and appropriate balance offrequency and intensity of the activity could havepotentially limited the in-depth understanding aroundphysical activity that needed to be extrapolated from theinterviews. Hence the intensity levels (mild, moderate andvigorous activity) had to be explained with examples aswell as giving descriptions of the impact the intensitylevel has on the body (in terms of breathing, bodytemperature, heart rate and perspiration) (DofH 2004).Dispelling participants’ subjective assumptions of whatrecommended physical activity is and elucidating the factthat the recommended amount of physical activityinvolves accounting for both the frequency and vigour ofthe activity helped gain a more vivid and accurateaccount of the physical activity of participants.

For a majority of the participants, the Tandrusti project’sexercise classes is the only session of physical activitythey do during the week and find it difficult to take timeout to exercise at home. When participants were askedabout why they didn’t continue the exercise at home, thereasons included; lack of physical space, lack of time,distractions from family, other responsibilities likehousework, looking after the children, and other day today chores taking precedence over physical activity.Moreover, physical activity was viewed as a chore or anextended activity and over half of the participants couldnot see how physical activity was not just restricted tothe stereotypical activities that quite often representbeing active such as going to the gym, going for a run orparticipating in sports. This was not exclusively a SouthAsian phenomenon and seemed to be an interpretation ofphysical activity held by other ethnic groups as well andseemed to be a product of socio-economic pressures andcultural capital. Heavy marketing of sports and sports’clothes and accessories has generated a narrow vision ofphysical activity with implicit messages that physicalactivity is for the young, healthy and able and clearlyunder-representing certain minorities and older groupswho may or may not fit the idyllic image of the individualwho is likely to be physically active. This coupled withfamily obligations and cultural traditions can restrict theparticipation of older South Asian women in thesestereotypical physical activities and Tandrusti has enabledmany women to venture these activities in a culturallycompetent and practically convenient way. However, themessage of continuing the physical activity beyond theclass is still a matter of further work and development forTandrusti.

17

Research Findings

The use of the gym and leisure centre facilities was non-existent among the participants; this was partly to dowith distance, cost and a lack of culturally appropriateenvironment and partly to do with the lack of exposureto these other venues of exercise. This further reinforcedthe notion of cultural capital and socio-economiccircumstances having an impact on the likelihood ofcertain groups participating in mainstream orstereotypical forms of physical activity. Therefore thisneeds an educative and guided approach to exemplifysuitable ways of being physically active outside the classwhich consider individual circumstances and are culturallysensitive. Contrary to some beliefs, attending a mixedgym was not favoured by most women regardless of theirreligious and cultural practices. It was a personal choicewhereby they felt more comfortable to exercise in anenvironment that they felt at ease in and where therewasn’t the pressures to conform to the norm or thenotion of ‘body beautiful’. Most women believed thatgyms have a strong youth, beauty and fitness basedethos and were lonely and isolated places; a key barrier toparticipating in physical activity.

“Its lonely exercising in the gym… its boring exercisingon your own.”

Health Service Use

Participants’ experiences of using the various healthservices were evaluated by focusing on their awareness,access, and satisfaction levels of the health servicesavailable to them. The most widely used service by allparticipants is the GP service and the main source ofhealth information and advice for a number ofparticipants. Overall the satisfaction with the GP servicewas quite high whilst the satisfaction with thebureaucracy and running of the GP surgery was quite low.It can be argued this is a manifestation of thegovernment’s effort to reduce waiting times and makeservices more efficient. However, it has restricted andcomplicated access for a number of people who are notable to keep up with new and constantly changingprotocols for booking an appointment to see their GP.This frustration was shared by nearly all the participantswho found the new appointments and booking systemsused by most GP surgeries very restrictive and not veryuser friendly. The GP service, is the pivotal point to mostother health services for nearly all participants and theGPs are also in a position of power whereby they canprovide access to specialist and further health services,but participants feel the process of gaining access ismade so wearisome and ‘frustrating’ that ‘it puts you offseeing the GP’. However, once access to the GP was

Melrose Logan is a Tandrusti student who is now actively volunteering on the project.She initially got involved in the project by attending one of Tandrusti’s Community

Gyms and found the rewards on her physical healthquite encouraging. She is keen to improveher health through healthy eating andexercising but also through knowledgeand understanding about anatomy andphysiology which she also gains fromher Tandrusti course. After training asa volunteer walk leader withTandrusti, she now regularly takeslarge groups for health walksaround Dudley and promotesand encourages the regularexercise message within thecommunity.

“I want to show how

exercise can be quite

exciting and varied and

doesn’t have to always be in

a gym… also the anatomy

and physiology knowledge

and awareness I have gained

from my Tandrusti course is

highly useful to me

personally and as a

volunteer.”

Case Study 2 - Melrose Logan

18

Research Findings

gained, participants were generally happy with theirconsultations and were mainly critical of the gatekeepers(surgery receptionists) who control access.

The second parameter used to evaluate satisfaction withthe health service was the satisfaction participants havewith the service outcome. What became apparent in theinterviews was the level of expectations differentparticipants had of the health services. Participants overthe age of 65, in particular participants from the southAsian background, had low expectations of the healthservices. They saw the process of getting access to seethe GP and taking someone to translate as the biggesthurdle and were consequently quite trusting of theprofessionalism of their GP and quite happy with thegeneral outcome. This was fine in a majority of cases butin a few cases the lowered expectations from the healthservices could be preventing a minority of older SouthAsians from recognising, questioning and challenginginequality or discrimination within the health services. Theextract from a participant below highlights this point:

“I’m happy if I see Dr Y, because he is understandingand very calm. When I See Dr X he talks to me veryangry and says that I should take my medication but Idon’t like taking the medication as it makes me sick.

He just says that if I don’t want to get better then Ishould go back to Iraq”Do you think Dr Xs behaviour or comments towards youwere racist?

“I’m not sure, I think the problem with him is that hethinks he is above me because he is a doctor …he’s notracist but speaks very angrily to me. He shouldn’t belike this because he is a doctor and he should careabout patients”

The participant in this interview was more anguished bythe tone and the aggressiveness in which the doctorspoke and overlooked the discriminatory comment abouther returning to Iraq if she didn’t want to comply with thetreatment and ‘get better’. This participant reported thatshe has been suffering from depression after losing mostof her family in Iraq, and felt this doctor’s approach to herhealth status was rather dismaying and patronising, hencetook the decision to change her GP.

On the whole experiences of discrimination and prejudicewithin the health services were quite low despiteexperiences of racial discrimination more generally insociety being on the increase particularly reported byMuslim participants. It has to be added that many older

Zaida Nazir is a mother of 4 children and a full time home-maker; she has been partof Tandrusti’s community gym for a couple of years now. Prior to attending the

Tandrusti she had not taken part in any organisedphysical activity or attended any gym or leisure centre.Tandrusti’s local and convenient service was thesuitable solution for her and her caringcommitments to her sick child. Throughher personal experience she has gainedunderstanding of how the physical andmental health are inter-related andhow they both affect one another.She has a keen interest in supportingpeople who have mental healthproblems which could affect their

physical health. She has personal experience of being passedaround from GP to consultant without getting adequateadvice and would like to train and gain information andsignposting skills that she could share with people withsimilar issues. She is particularly interested in supportingmothers who have poor command of English and who maynot have the social support networks either due to beingnew migrants and or family obligations.

“Being a CHC will be

helpful to me, as the

training I will get will help

me first and then I can help

others like me, I would have

appreciated if something

like this happened earlier in

my life.”

Case Study 3 - Zaida Nazir

19

Research Findings

BME participants interpreted discrimination and prejudicein an overt sense in terms of comments, actions andhostile stares and did not pay due attention to the morecovert and subtle forms of discrimination that may ormay not be affecting their health service experiences.Contrastingly younger participants observed more subtleforms of discrimination which they claimed was largelydispensed by administrative and nursing staff in thehealth services and on the whole was directed towardsolder BME members and/ or with a poorer command ofEnglish.

The awareness of additional health services andparticularly preventative health services was quite lowamong participants and these other health services weremainly accessed via their GPs once they had developed aparticular condition, ailment or illness to qualify for thatservice/treatment. For example there were only fourparticipants who knew about services like NHS Directand the NHS Drop in centres. This reinforces a pointraised earlier about awareness of one’s health arisingwhen confronted with the symptoms of an illness ordisease. Similarly participants’ use of health services waspredominately for curative purposes and rarely for advice,guidance and information on preventing ill health. Thereason for this was that, participants simply did not knowof their existence, how they may be able to help and howand where to access them from, which highlights a needfor more guidance and information on how to use suchservices. This will in turn assist in freeing up GP time.

‘Cultural’ factors

There were a number of culturally related factors whichhad some impact on the research process and findingsand therefore need to be highlighted as integral aspectsto understanding the particular health experiences of BMEgroups. The problem in defining ethnicity due to therelativity and ambiguity that surrounds it may appear toplace the blame of poor health on the ethnicity of theindividual. The indicators used to define ethnicity arevaried and multidimensional and there might be somemisunderstanding of the term ethnicity with notions ofrace. Therefore, the term culture is used rather thanethnicity to avoid this confusion and move away fromdisproved and discredited biological and geneticallydetermined theories which may be regarded as anarbitrary label without a definable scientific theory.

Culture is broadly seen as a set of guidelines which statehow to view the world, how to experience it emotionallyand how to behave in it in relation to other people. Theseguidelines are often passed on to the next generation toprovide cohesion and continuity of a society. Nonetheless,the term culture in itself is a social construct that isconstantly changing and notoriously difficult to measureas a result of subcultures and the diasporas of culturesemerging and evolving with migration and demographicchanges. The indicators used to define and operationalise

culture or ethnic background for this analysis were theself defined ethnicity categories from the 2001 Censuswith non white British groups constituting Black andMinority Ethnic groups. Also the ethnic background labelsthat participants gave themselves helped to confirm theethnic background that participants affiliated with moststrongly.

Some cultural aspects had an impact on the researchprocess and also the research findings. Having a sharedethnic background with the majority of participantsenabled probing into some of the comments made by theparticipants. In particular when describing one’s health, itwas noticed that participants described their personalhealth more modestly due to the fear of getting ‘nazar’ orthe evil eye. This superstitious belief and some womenbelieving in sorcery was having an influence onparticipants’ (particularly older south Asian women)interpretation of the causes of mental, physical and socialproblems.

“Its hard to say because sometimes these illnesses justcome out of nowhere and the next thing you know youbecome badly ill… I mean perfectly healthy peoplebecoming so sick makes you wonder what other peoplemight have done on you (referring to sorcery) .”

“All the time… its happened to my granddaughter whois a really beautiful and healthy baby who from birth tillthe age of one has given no trouble to my daughter andeveryone used to comment on that, and then just aftera neighbour said she was such a lovely and wellbehaved baby she became quite sick and ever sincethat she gets sick all the time… I told my daughter thatyou shouldn’t flaunt her about in this way and tellpeople that she is not feeding properly or she has hada temperature, you know just to take the nazar off herbut the kids from the new generation don’t listen tothings like this.”

The superstitious views held by a few of the South Asianwomen, whilst others had somewhat fatalistic or passiveapproaches to understanding their health status. However,despite individual understanding and recognition of healthstatuses, the desire to implement changes however smallor large were present in many participants. It has to besaid that modest or poor descriptions of health portrayedparticipants as vulnerable which in turn promotescommunity and support among some South Asiancommunities. This may also have an effect on the wayhealth is described by different ethnic groups in largequantitative surveys like the Census which do not accountfor subtle differences in the way groups or cultures mightperceive health and well being. This had to be consideredat the interview stage of this research in order to fullyunderstand why participants described their health in theway that they did, whilst ensuring that their healthdescriptions were not assumed to be exaggerated.

20

Research Findings

The issue of ‘purdah’ (literal and metaphorical veiling fromthe opposite sex) particularly for the Muslim femaleparticipants was also reported to be a significant barrierto them participating in mainstream physical activities.This was twofold in that they felt uncomfortable toexercise in a mixed gender environment and also theirpartners or family would disapprove of them exercisingwith men. Although many women reported to feelinguncomfortable exercising with men, Muslim women weremore likely to state religious or cultural reasons as themain prohibitions.

“…if you look at those two women (pointing out twowomen in hijaab/veil) they would not be able toexercise in a mixed environment. Or if they exercised ina mixed cultural gym with white women they may notfeel very comfortable as they are not in standard gymclothes.”

“I think its because of the way we were brought up…Our culture has segregated men and women for mostthings like schools, mosques and so on, I think it justfollows on from there. I just feel more comfortablebeing around women as that’s what I have been usedto.”

“My husband only allows me to attend a female onlyexercise environment and when I first heard about thisclass I was really excited as it was local and I thought Icould go to the class and then go to pick my kids fromschool so it fits in well with my routine.”

“Having a female fitness tutor is so great… youwouldn’t get all these things in gym. When you go to agym you don’t get a tutor and you have to pay a lot ofmoney and also the nearest gym in this area is so farthat I wouldn’t be able to walk there.”

The comments highlight the culturally competent qualitiesof Tandrusti in being able to make exercise possible forMuslim women who might not have been able to takepart in formally organised exercise. In addition theconfidence of a number of women has grown sinceparticipating in Tandrusti. This was measured by theirdesire to pursue other courses, take more involvement inTandrusti as volunteers, being able to walk for longerdistances, increase independence and even to supportcommunity activities through the local community centreat which the courses are held.

The importance of having goodMental Health

Mental health is fundamental to overall health andproductivity. It is the basis for successful contributions towork, family, community and society. Throughout thelifespan, mental health is the wellspring of thinking andcommunication skills, learning, resilience, and self-esteem.The focus on health from a predominately physical

approach can minimise or deter attention from theindividual’s overall health which is a “state of completephysical, mental and social well-being.”(World HealthOrganisation, WHO).

Despite the diversity in South Asian communities, thereare many common cultural elements. Most of the culturesare strongly rooted in the family and extended family. Therole of each family member is well-defined. Elders arerespected, elderly parents quite often live with and arelooked after by their children. A strong system of supportand co-dependency develops naturally in families. Mostdecisions are made in light of what is best for the family. From discussions with participants, it was revealed thatthe South Asian community generally do not discusspersonal or mental problems with anyone outside thefamily. Often, shame and guilt are used to enforce thesenorms in the family, therefore this may lead to anxietyand depression. The South Asian attitude towards mentalhealth is complex. Open discussions of an individual'semotional problems bring shame and guilt to the family,preventing any family member from reporting suchproblems to others outside the family. Having goodmental health is not given as much precedence as havinggood physical health simply because talking about mentalhealth prompts discussions about emotional and socialissues which are seen as highly personal and confined tothe immediate family. Consequently discussion aboutsocial/emotional issues outside the family is seen as‘washing the dirty laundry in public’ and may contradictnotions of honour and moral standing in the communityparticularly if the issue is not viewed favourable by thecommunity.

There were several women in particular who describedsymptoms of depression or at least some form of mentaldistress but did not acknowledge to themselves oranyone the possibility of depression. Being depressedwithout an acceptable natural cause (i.e. bereavement,illnesses) implies social dysfunction and ultimatelydamages the family honour and reputation which is builtover generations of compliant individuals.

“Everyone has problems but you can’t go and talk toother women outside, they will listen to you at the timebut they will laugh at you and judge you later.”“If have any kind of problem I usually I just deal with itmyself, I try to pray when I feel depressed and needsomeone to talk to….I don’t want unnecessary gossipand behizti (shame) on my family.”

The latter comment illustrates the need for moreawareness of culturally competent mental health services.Furthermore it is simply not enough to have services incommunity languages; attention needs to be paid to theintricacies of the cultural practices, such as the criticalneed for anonymity and understanding of culturalbehaviours and values.

21

What function has Tandrusti Projectserved in improving the Health ofBME groups in Dudley?

The role of Tandrusti is to provide a culturally competentcommunity health and fitness education programme whichis easily accessible and convenient to use for the socalled ‘hard to reach groups’, who are likely to suffer thehighest health disadvantage. Tandrusti’s success has beenevidenced by lowered Blood Pressure (BP) readings inover 90% of its service users. The coronary heart disease(CHD) Prevention Programme at Dudley PCT analysed thedata on learner BPs collected by tutors and summarised amean reduction of 3.517 in Systolic and 3.117 in theDiastolic from start to end which is a significant reductionat this level (Tandrusti Annual Review 06/07). What ismore, testimonies by learners describe significant changesin flexibility, stamina and energy levels after joining theTandrusti course. As mentioned earlier, Tandrusti is theonly physical activity that many of the participants do inthe week moreover, for many Tandrusti is the firstorganised exercise experience they have had in the theirlives which in itself is quite a break-through. Therefore,satisfaction with the Tandrusti course was very high, interms of delivery, time and venue.

Tandrusti is genuinely perceived as providing analternative if not better service than that of the gym or

the leisure centre for those who were able to compare.Where the local gyms or leisure centres fall short,Tandrusti has been able to deliver in terms of free,friendly, local and tutor led physical activity session. Inaddition the benefits of the health education programmeextend beyond the physical and for many Tandrusti is ameans of social and emotional support and a way ofescaping family commitments and daily chores for a shortwhile, this was referred by one participant as “Me Time”.Furthermore, numerous BME women described symptomsof depression; but only three of them were getting help oracknowledged they were depressed, for many of thesewomen who were depressed or suffering from low moodsaw Tandrusti as a support mechanism. This was essentialas very few participants included their mental health inthe discussion about their overall health unless probed. Itseems although making immense changes in health-lifestyles for older participants were seen as potentiallystressful and traumatic, Tandrusti is seen as a positiveway forward and an achievable hurdle to changing life-long habits and way of life.

“I have noticed changes in my health, my son used todrop me at the class before and now I can walk to theclass, I never thought I would be able to walk that kindof distance, its not very far but if you have arthritis andhealth problems it seems very very far….. that has madea big difference to my life…..”(Tandrusti Male Student in 60s)

Research Findings

Delores Rhooms is a part time cook by profession and has been attending Tandrusti’sCommunity Gym for several years. She feels she has grown in confidence though

mixing with people of all ethnicities and ages andtaking part in student led exercise. Sheoffered to volunteer for Tandrustibecause she would like to raiseawareness of healthy eating amongthe Afro Caribbean community.She has many years of cookingexperience and would like tosuggest tasty ways of cookingmore healthy food. She findsvolunteering work to berewarding and also

distracting from the daily routine of work and lookingafter her family.

“I see some friends and

relatives and they eat a lot of

heavy food, and they will

have no fruit and vegetables

in their meal, I want to help

the older people in my

community who don’t pay

much attention to their food.”

Case Study 4 - Delores Rhooms

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Research Findings

“Tandrusti is good for my health but also it has givenme so much more, I have made some good friends andwe all support one another with being healthy, I feel Ican release a lot of pressure when I come here and Ifeel lighter and refreshed when I go home.”(Tandrusti student, female, aged 59)

From observations and talks with participants it becameclear that every Tandrusti class has its individualatmosphere based on the variety of experiences thattutors and students bring to the class. Yet they all sharea common ethos of respect, care, camaraderie andencouragement. This according to participants has been akey strength of the project and being able to recruit newstudents whilst retaining existing ones. This was evidentin participant observations of classes and it was clearthat there was a significantly high level of socialmotivation behind coming to the exercise class. Althoughthis is a positive aspect of Tandrusti in initially attracting‘hard to reach groups’ to take part in exercise, it alsoneeds to be ensured that the motivation behindexercising is essentially led by the desire to improve one’shealth. This type of motivation is essential to long termembedded health motivation and health improvement thatis sustainable beyond the Tandrusti class. Nevertheless,

participants suggested that having more exercise sessionsduring the week would build on the work that they did intheir main session. Participants also suggested thatadditional activities, equipment and integrating furtherhealth education into fitness education would also be anasset to their health education in the medium to longterm.

The findings from this research have been used to developa sustainable health education programme which is firmlyrooted in the community’s structure and where thestudents themselves can be more proactively involved inimproving their health. Consequently the research hasbeen able to recruit 25 volunteer Community HealthChampions (CHCs) from a diverse range of ethnicbackgrounds and age groups who are committed toTandrusti and its objectives. These CHCs are being givenappropriate training and support to be able to volunteerin the areas that they have an interest and passion in. Itis anticipated the scheme will snowball and students willdevelop a heightened knowledge and understanding ofhow to be healthy along with becoming active leaders intheir communities to positively influence the health andlives of others in their community.

Conclusions

In Britain generally, black andminority ethnic (BME) groups bear adisproportionate burden of disease,injury, premature death, anddisability.

For BME populations, health disparities can mean lowerlife expectancy, decreased quality of life, loss of economicopportunities, and perceptions of injustice. For society,these disparities translate into decreased productivity,increased health-care costs, and social inequity. By 2050,ethnic minorities will account for nearly half of the totalUK population (based on Office for National Statistics2001 population projections). If these populationscontinue to experience poor health status, the expecteddemographic changes will magnify the adverse impact ofsuch disparities on public health in Britain.

Despite recent progress, ethnic disparities persist amongsome key health indicators identified in the Our Health,Our Care, Our Say (2006) government white paper.Socioeconomic factors (e.g. education, employment, andpoverty), lifestyle behaviours (e.g. physical activity,alcohol intake, and tobacco use), social environment (e.g.educational and economic opportunities andneighbourhood and work conditions), and access topreventative health services (e.g. culturally competenthealth promotion, cancer screening and vaccination)contribute to ethnic health disparities. In addition thelevel of education has been correlated with theprevalence of certain health risks (e.g. obesity, lack ofphysical activity, and cigarette smoking). Furthermorewith the current transient demographic climate, recentimmigrants are likely to be at risk from chronic diseaseand injury among certain populations. Although someimmigrants are highly educated and have high incomes,the lack of familiarity with the British health-care system,different cultural attitudes about the use of traditionaland conventional medicine and lack of fluency in Englishcan pose as barriers to obtaining appropriate health care.Addressing these issues is highly pertinent for our societyand health care system in the medium to long term.

The Tandrusti research objective was to document thehealth status of BME groups in the Dudley area, toidentify health disparities and also draw out practicalways of working with the community through Tandrustivia an embedded approach. The findings revealed that thedisparities identified in this research have some resonancewith large scale and national research carried out in thisarea. Overall health awareness has shown improvementamong BME groups with the intense and universal healthpromotion in recent years. As health messages andpromotion have become more persistent and prominent inthe last decade globally, people too have started to takeheed of the messages. Thus although the battle of raisingawareness is half won, the more challenging battle ofchanging people’s habits and lifestyle’s necessitates acultural shift from fast food and sedentary lifestyles toone that allows and supports dietary care and physicalactivity. This may raise questions about the verystructure of our society, our work place cultures and thegeography of our environments which all have a role toplay in the construction of our habits and lifestyles. Thecurrent structures in our society do not make it easy tobe healthy; at present being healthy is a much deliberatedchallenge that requires a high degree of motivation.Tandrusti is one platform that raises motivation towardsfitness but this research has raised several issues for localand societal consideration and highlighted issues thataffect both BME and non-BME groups.

In short the decision to be healthy is not simply anindividual one but bound by many inter-relatingdeterminants which impact the habits and lifestyles ofindividuals. Therefore it is our collective responsibility towork together towards making being healthy a trouble-free option and a way of life rather than an alternative tothe norm, favouring those who are financially,educationally and culturally at an advantage.Subsequently, health education is vital to re-distributingthe cultural capital that the more educated and highersocio-economic groups benefit from. Whilst this maysupport changes at a local and individual level, widerstructures also need to ensure that our environment cansupport and facilitate healthy lifestyle changes.

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Recommendations for BME and alsonon-BME individuals

n Engage in regular (30 minutes of moderate activityfive times a week) physical activity and reducesedentary activities to promote health, psychologicalwell-being and a healthy body weight.

n Maintain body weight in a healthy range, balancecalories from foods and beverages with caloriesexpended.

n Prevent gradual weight gain over time, make smalldecreases in food and beverage calories and increasephysical activity.

n Consume a variety of nutrient-dense foods andbeverages within and among the basic food groupswhile choosing foods that limit the intake of saturatedand trans-fats, cholesterol, added sugars, salt andalcohol.

n Improve physical fitness by including cardiovascularconditioning, stretching exercises for flexibility andresistance exercises for muscle strength andendurance.

n Participate in local community organisations which canbe an effective link/information source to keyhealth/community services in your community.

n Be proactive about finding out about key healthservices by asking your GP, local PCT, district nurse orcommunity health organisations.

n Find ways to regularly monitor your own health, suchas checking body weight, keeping a diet and fitnessdiary and being more critical about food consumedand the amount of physical activity undertaken.

n Share good health practices and messages with family,friends and people in the community and motivate andencourage others to be healthy.

Recommendations for communityorganisations and communityfitness services

n Build a culture of collaboration with communitiesbased on trust.

n Equip individuals and communities with the knowledgeand tools necessary to create change by seeking anddemanding better health and building on the resourcesand capacities that exist within the community.

n Develop awareness of and have involvement in healthinitiatives/promotions/services which deliver aculturally competent service and will be easilyaccessed by BME groups.

n Design health initiatives in education and orcommunity activities that acknowledge and are basedon the unique historical and cultural context of BMEcommunities in Dudley.

n Assess and concentrate on the underlying causes ofpoor community health and implement solutions thatare embedded in the community’s infrastructure.

n Recognise and invest in local community expertise andmotivate individuals and communities to mobilise andorganise their resources, skills and volunteering.

n Embrace and partner with valued communityorganisations, including those whose primary missionis something other than health.

n Activate leaders and key organisations that arecatalysts for change within their communities (i.e.effective community workers within grass rootorganisations)

n Develop a collective outlook that promotes sharedinterest in a healthy future through widespreadcommunity engagement and leadership.

n Focus on changes to certain lifestyles, habits,community environments and policies so that healthimprovements will be long–lived and make plans forself–sufficiency of partnership activities andprogrammes.

n Foster optimism, pride and a promising vision for ahealthier future.

24

Recommendations

25

Recommendations for health careorganisations, policy makers andHealth education professionals

n Increase awareness of ethnic disparities in health careamong the general public, key stakeholders andhealthcare providers.

n Increase the proportion of under represented blackand minority ethnics among health professionals.

n Use evidence based practice guidelines; enhancepatient provider communication and trust.

n Ensure adequate resources are allocated to meet theneeds of patients likely to suffer health inequality anddisadvantage.

n Provide appropriate interpretation services wherecommunity need exists.

n Ensure health promotion is culturally competent;consider issues of user background, literacy levels,accessibility and the translation and appropriatenessof health messages to user lifestyles.

n Consider incorporating and developing communityhealth workers/ volunteers to support and implementmulti-disciplinary treatment and preventative careprogrammes.

n Implement patient education programmes to increasepatients’ knowledge on how to best access healthcare and participate in treatment decisions.

n Integrate cross cultural education into the training ofall current and future health professionals.

n Collect data on healthcare access and utilisation bypatients’ ethnicity and socioeconomic status. Reportethnicity data and monitor the progress towards theelimination of health care disparities.

n Commission research to identify sources of ethnicinequalities, on barriers to tackling inequalities and toassess intervention strategies to reduce inequalities.

Recommendations

26

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Registered charity number: 1112775. Company limited by guarantee in England and Wales no:2806910. Registered office: 3rd floor, 70 Clifton Street, London, EC2A 4HB

Our Health, Our Action Tandrusti Research Report

Report by: Iram NazProject Researcher – WEA West MidlandsEmail: inaz@wea.org.uk

Tandrusti Project Manager: Harjinder KangEmail: hkang@wea.org.uk

WEA West Midlands 4th floor, Lancaster House 67 Newhall StreetBirminghamB3 1NQ

Tel: 0121 237 8120Fax: 0121 237 8121

Email: westmidlands@wea.org.ukWebsite: www.westmidlands.wea.org.uk

Release Date: November 2008